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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) Date Issued ---9/ / <br /> _� �7— <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549, <br /> j l <br /> JOB ADDRESS AND OCAT10N-- F ----------------------------------------•---..-------------------------------------- <br /> Owner's Name �.� ---- ---- --- _ Phone------------------------------------- <br /> Address - -------------------------------------------------------------------------------------------- <br /> - .-- ... �7- <br /> Contractor's Name------ -------- ---- ---------------------------------------------------------------------------------------------------- Phone----------------------------------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: Number of bedrooms _ _ Number of baths -------- Lot size ---- -----------_-__-------._--____--__.--.--------_-_--- <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam p Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No New Construction: Yes ❑ Nohkj` <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well_1%7_�-+�.Distance from foundation:M____---____.Material _ ,,--- -------------___-. <br /> " ! No. of compartments------>�--------------Size--&__A --- ---Liquid depth----�----------------Capacity_._`9- ----0------ <br /> Disposal Field: Distance from nearest well_.A/Lrk.,.i,._Distance from foundation..._J-0---------Distance to nearest lot line.-_--Sti-------- VZ <br /> Number of lines----------/........ ... .�.. =ngfhf each line___�0,-----------_.Width of,french___c_-.K_Z-----__------- <br /> ­21 <br /> Type of filter material filter material----'/_ ----------Total length__---- ',S ------------------------_ <br /> . 6 <br /> Seepage Pit: Distance to nearest well___ 63 „___Distance from foundation.. d <br /> J...............Datance to nearest lot line______-_________ <br /> i <br /> Number of pits._._.__�__.._______Lining matertal__�'_.�____f��'Size: Diameter_�._�_...-------Dept h------�-�,�___.___._________ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------ <br /> ------------------- <br /> F1 <br /> -----_-_-,_,__ <br /> ------------------- ti.. <br /> ❑ Size: Diameter-------------------------------------Depth----------------------------------------- ----------Liquid Capacity---------------- ------gals. <br /> Privy: Distance from nearest well-----------------------------------------------.-Distance from nearest building-------------..-_-_-----_-_--_.-________- <br /> ❑ Distance to nearest lot line ----------------------------------------------------------- _ <br /> i <br /> Remodelingand/or repairing (describe):------------------------------------------------------------------------------------------------------------------I-----------•------------------------ <br /> ------------------------------------------------------------------------------------•-----•--------------------------------------•----•------------------------------------.------.--.---------------------------------------- <br /> ---------------------------------------------------------•-------•-----•-----•---------------------------------..............-----------------------------------------------------.....------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------•----------------------------------------- -------------------------------------------------------- -------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulationsf the San Joaquin Local Health District. <br /> (Signed)- - AII---- ---- -- --------- --- ------------------------------------------------------------------------------ ------(Owner and/or Contractor) <br /> By:_---------------------------------- -------- -- ---------------------------------------------------------------------------------(Title)---------------------------- <br /> ----------- ------------ <br /> (Plot plan, showing size of lot, locati of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----------------------------- ----- -------------------------------•---------------- DATE--- <br /> REVIEWED BY------------------------------------------------------- ----------- <br /> ------- -------------•---------------------------------------- DATE- .. <br /> BUILDING PERMIT ISSUED------------------------------------- - DATE--------- --------- <br /> Alterations and/or recommendations-- --------------- �� � <br /> -------- ----------------------- --------- <br /> ----------- <br /> l �� ---- ------------ ---- ---- -- ----- - - ----------- <br /> --- - --- -- ------ ------------- <br /> _! ------ -- ------------------ <br /> -_. <br /> ---------- - <br /> _T • --.... --------------- -------------------- - <br /> ------------------------------------- — o --5 ---- -,.�-- ------ - <br /> FINAL INSPECTION BY:-----•+ ,.5------------------- ------------- Date---------�w- L CS <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Streof 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> E5-4-2M � -- Revised W-2100 <br />